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inborn errors of metabolism – biochemical
basis
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What is an inborn error of metabolism (IEM)?
Genetically determined biochemical disorders, that affect an individual’s ability to convert
nutrients or to use them for energy production.
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Majority of IEMs are due to defect in a single gene that code for an :
ENZYME
COFACTOR
TRANSPORTER
Most of them are inherited in an autosomal recessive pattern
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Fundamental design of the normal metabolic pathways and effects of metabolic aberrations
GARROD’S HYPOTHESIS
A B C D
E F
METABOLICBLOCK
Substrate accumulation
Accumulation of byproducts
Product deficiency
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IEMs affecting mother and fetus
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diagnosis Prenatal diagnosis
Newborn screening
Evaluation of symptomatic patients
Postmortem screening
Analysis of 1) Metabolites 2) Enzymatic activity 3) Molecular structure
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classification
Three broad categories: Based on the effects of their metabolic
derangement.
1. Intoxication type 2. Energy deficiency type
3. Disorders of complex molecules (storage type)
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Disorders of amino acid metabolism
INTOXICATION EFFECT
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Disorders of amino acid metabolism
Defects in aminoacid catabolism
Urea cycle
defects
Glycine
Nonketotic hyper
glycinemia, Primary hyper
oxaluria
S containing aminoacids
cystinuria, homo
cystinuria, cysta
thioninuria
Branched chain a.a
MSUD
Aromatic a.a
PKU, alkaptonuria,
hyper tyrosinemias
Defects in aminoacid membrane transport
Cystinuria
Hartnup’s disease
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Aromatic amino acids
Tyrosinaemia I
II
Tyrosinaemia III Fumaryl
acetoacetase
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Classic Phenylketonuria And
Other Hyperphenylalaninemias
DHP reductase
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PHENYL ALANINE*
PHENYLALANINE HYDROXYLASE
PHENYL ACETIC ACID*
HYDROXY PHENYL LACTIC ACID, PHENYL
PYRUVIC ACID
phenylketonuria
Blood phenylalanine (30-80mmol/L) Urine – phenyllactic, phenylacetic Urine pterin profile -Neopterin and biopterin , primapterinActivity of dihydropteridine reductase in blood cells 5-HIAA and HVA in CSF
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3) DiNitroPhenylHydrazine
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tyrosinaemias
TYPE I – Hepatorenal tyrosinaemia
Fumaryl fumarate acetoacetate acetoacetic acid
Fumaryl acetoacetate hydrolase
Succinyl acetone
ALA PBGALA dehydratase
•Elevated conc. of tyrosine•Urine – succinylacetone•ALA and succinylacetone in blood•Alphafetoprotein
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TYPE II –
Tyrosine P-hydroxy phenyl pyruvate
Oculocutaneous tyrosinaemia – painful corneal erosions and plaques, inflammation and keratosis of palmar surface
Tyrosine transaminase
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alkaptonuria
Homogentisate
benzoquinone acetate (urine)
black alkapton bodiesFerric cloride test- purple black
Benedicts test- brown colour
Ochronosis
Maleylacetoacetate
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Tyrosine
Tyrosinase
DOPA
Albinism
DOPA quinone
Dopachrome
Melanine
Tyrosinase
ALBINISM
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Disorders of branched chain amino acid
metabolism
•High plasma conc of branched chain aa’s•BC ketoacids, oxoacids and hydroxy acids – urine•Odor of maple syrup – smelling ear wax•alloisoleucine•Positive DNPH test•FeCl test- greenish grey color
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Disorders of
sulfur containing aa’s
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Propionyl Co A
α- KB dehydrogenase
Biosynthesis of cysteine
Homocystinuria
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Accumulation of homocysteine,
Deposited in various tissues
Binds copper and interferes with maturation of collagen and elastin
Skeletal deformities, posterior dislocation of lens,mental retardation, increased susceptability to thrombosis .
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•Disulfide homocystine levels
•Total and free homocysteine levels (immunoassay, HPLC, tandem mass spectrometry)
•Methionine levels (B.U)
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Urea cycle
Hyperammonemia without metabolic acidosis – defect of
the UREA CYCLE
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Acetyl –CoA + glutamate
N-acetyl-glutamate
CO2 + NH3 + 2 ATP carbamoylphosphate +MITOCHONDRION Ornithine Ornithine OTC ORC1 Aspartate Citrulline (HHH)
CYTOSOL CITRIN ORC1
Aspartate + Citrulline ASA synthase ASA lyase Arginosuccinic acid
Orotic acid
UTP, CTP
NAG synthase
Arginase UREA
CPS-I
fumarate + Arginine
carbamoylphosphate
CITRIN
ORC1
ORC1
HYPERAMMONAEMIAS
Hyperammoniemias, abnormal liver functions, elevated transaminases, abnormal PT/PTT ratio, plasma aa’s (glutamine and alanine), urine amino acids
Low conc of citrulline with elevated glutamine – NAGS, CPS-1 and OTC deficiency
Urine orotic acid – OTC deficiencyElevated citrulline – citrullinaemia type I (ASA deficiency) - type 2 (citrin deficiency)
ORC1 deficiency – HHH syndrome – hyperammonaemia, hyperornithinaemia, homocitrullinuria
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Disorders of amino acid transport
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Degradation of tryptophan – indoleyl acetic acid and indolyl acetyl glutamine – neurotoxic action – neurological symptom
Pellagra like symptoms
Blood: plasma levels of tryptophan↓
Urine shows ↑ amounts of IAA (Obermeyer test)
Hartnups disease
Results from defects in intestinal & renal transport of neutral aas like tryptophan (neutral AA transporter).
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CYSTINURIA: renal and GIT transport of cystine and dibasic aa’s–
defective Cystine – insoluble Precipitates in the renal tubules Cystine calculi - nephrolithiasis. U- cystine, lysine, ornithine, arginine
Lysinuric protein intolerance Cationic amino acid transporter Failure to thrive, alveolar proteinosis,
hepatosplenomegaly, pancreatitis, diarrhea, osteoporesis, hypotonia, postprandial hyperamonemia
Lysine, arginine, ornithine – U Orotic acid - U
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Organic acidaemias
Hyperammonaemia with metabolic acidosis and ketosis –
ORGANIC ACIDAEMIAS
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Accumulation of intermediates in the catabolic pathways of amino acids
intermediates – water soluble (carboxyl groups)
Physiologic metabolites present in excessive amounts/ metabolites not normally present
Metabolic acidosis – 6.85 to 7.3Low bicarbonate - <5-15 mmol/LSignificant anion gap
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Propionic aciduriaMethyl malonic aciduria
Propionyl CoA carboxylase
Methyl malonyl CoA mutase
•Propionyl carnitine•Methyl citric acid•MMA
Vitamin B12 lysosomal release
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Biochemical effects in propionic acidaemia
Increased organic acids Ketosis and metabolic acidosis with secondary Hyperammonaemia and Hyperglycinemia
Increased glucose utilization Hypoglycemia and Ketosis
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•Severe metabolic acidosis•Hyperammonaemia• chracteristic odor of sweaty feet• urine organic acid analysis -
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3-OH glutaric acid – UrineGlutary carnitine - plasma
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Carbohydrate metabolism
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GALACTOSE METABOLISM
SORBITOL/
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Aldose reductase
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Galactitol accumulates in lens and causes cataracts
Excess gal-1-p inhibits glycogen phosphorylase and phosphoglucomutase – impede glycogenolysis – accumulation of glycogen in the liver-jaundice;Feeding difficulties and vomitings – poor weight gain
Galactosaemia –persistent stimulus for insulin secretion by pancreas - hypoglycaemia , Abnormal lethargy or irritability
Renal failure- albuminuria and aminoaciduria
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Effect on erythrocytes:Galactose
Inhibits glucose-6-phosphate dehydrogenase
HMP – Shunt
Reduces the supply of NADPH
haemolysis
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FRUCTOSE METABOLISM
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Disorders of the carnitine cycle and fatty acid oxidation
ENERGY DEFICIENCY
Hypoketotic hypoglycaemia with/witout hyperammonaemia –
FATTY ACID OXIDATION IMPAIRMENT
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Fasting or high energy demands
Fatty acids are releaed from adipose tissue
Impaired oxidation of fatty acids
Accumulate in liver, heart, skeletal muscle Cardiomyopathy, myopathy,
Fatal arrythmias
Fasting or high energy demand – fatty acids – main substrates for energy prodution in liver, cardiac and skeletal muscle
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Lack of acetyl CoA
Dec. Gluconeogenesis
Excesssive utilization of glucose
Hypoglycaemia
Dec in energy supply to the brain
LOC, seizures and coma
Decreased availability of ketones
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CARNITINE CYCLE
Carnitine –essential role in the transport of LCFA inside mitochondria for -oxidation
Medium and short chain fatty acid - independent
OCTN2 – carnitine transporterCPT-1 – carnitine palmitoyl transferase 1CACT- carnitine-acyl carnitine translocaseCPT-2 - carnitine palmitoyl transferase 1
Hypoglycaemia No ketone bodiesHyperammonaemiaElevated liver transaminaseOccasionally – Creatine kinase activity
Carnitine uptake defect•Urinary carnitine wasting•Low serum free, total and acylated carnitine conc(25-50µmol/L)
CPT-I deficiency:Elevated FFA levelsLow long-chain carnitineElevated free carnitine/(C16+C18) ratio
Carnitine-acyl carnitine translocase deficiency
•Elevated conc of long chain acyl-carnitine levels•Low free carnitine levels
CPT 2 deficiciencyElevated long chain acyl carnitine levels with no carnitine deficiency
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-Oxidation defects
VLC acyl-CoA dehydrogenase deficiencyTrifunctional protein deficiencyHypoketotic hypoglycaemiaElevated CK and transaminaseElevated acyl carnitineSpecific enzyme assay
Medium chain acyl-CoA dehydrogenase deficiency urine acyl glycine, dicarboxylic acidsShort chain acyl Co-A dehydrogenase deficiency butyryl CoA – ethyl malonic acid, butyryl glycine and butyryl carnitine levels
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Glycogen storage disorders
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COMPLEX MOLECULES
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Lipid storage disorders
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Thank you
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references
Teitz textbook of clinical chemistry and molecular diagnostics – fifth edition
Clinical biochemistry- metabolic and clinical aspects – churchill livingstone
Indian journal of Practical pediatrics. Vol.12 No.2 APR.-JUN.2010